LE Response to Mental Illness: Practice and Policy

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Law Enforcement Responses toPeople with Mental Illnesses:

A GUIDE TO RESEARCH-INFORMEDPOLICY AND PRACTICE

Melissa Reuland

Matthew Schwarzfeld

Laura Draper

Council of State Governments Justice Center

New York, New York

Supported by


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Contents

Executive Summary .............................................................................................v

Acknowledgments .............................................................................................vii

Introduction ....................................................................................................... 1

SECTION ONE:Enconters Between Law Enforcement and People with Mental Illnesses .......... 3

SECTION TWO:

Specialized Law Enforcement Strategies ........................................................... 9

SECTION THREE:

Ftre Research Topics and Implications for Polic and Practice ..................... 13

Conclusion ....................................................................................................... 15

Appendix A: Understanding Apparent Inconsistencies inLaw Enforcement Research ............................................................................... 17

Appendix B: Detailed List of Research Questions .............................................. 19

Notes ...............................................................................................................21

Bibliography .................................................................................................... 23


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Executive Summary v

The complex nature o law enorcement responses to people with mentalillnesses has become an issue o national concern. Tese calls or service areoten time-consuming and dicult to resolve, and, on relatively rare occasions, result in tragicinjuries or deaths. Policymakers, community leaders, and the public are demanding better

outcomes rom these encounters. In the ace o this mounting pressure, and with a desire to improvetheir interactions with people with mental illnesses, law enorcement ocers are turning to specializedresponses. Tese eorts show great promise or increasing the saety o everyone involved and connectingindividuals to needed mental health supports and services when appropriate. However, policymakers

generally implement these programs without the benet o research and data documenting the scopeand nature o the problem in their community, the weakness o past response models, and the relativeimportance o specic program eatures.

o ensure law enorcement policies and practices related to people with mental illnesses are datadriven and well-inormed, this guide summarizes the available research on law enorcement encounterswith people with mental illnesses and strategies to improve these interactions.

Exectie Smmar

Enconters Between Law Enforcement and People with Mental Illnesses

Ocers encounters with people with mental illnesses are relatively inrequent, but they can be

particularly challenging. Tese encounters

oftentakemuchmoretimethanothercallsforservice,

requireocerstohavespecialtrainingandskills,

maydependontheavailabilityofcommunitymentalhealthresourcesforsuccessfuloutcomes,

typicallyinvolverepeatcontactswiththesameindividualswhohaveunresolvedmentalhealthneeds,

aremostlyinresponsetoapersonwithmentalillnesscommittingaminorornuisanceoense,

occasionallyinvolvevolatilesituations,riskingthesafetyofallinvolved.

Ocers generally have broad discretion in how they address minor oenses, or calls when no crimehasbeencommittedbutcitizensorbusinessownerswantthemtodosomethingaboutanindividualwhose actions are causing concern. Ocers handle a majority o these incidents inormally by talkingto the person at the scene without taking him or her into custody. Tese encounters provide ocersan opportunitysometimes missedto link individuals to eective interventions, which may preventsubsequent law enorcement encounters.


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Law Enforcement Responses to People with Mental Illnessesvi

Specialized Law Enforcement Strategies

Law enorcementbased specialized responses can create positive changes or all individuals involved,including the ollowing:

improvingocer saety

increasingaccess to mental health treatment, supports, and services

decreasingthe requency o these individuals encounters with the criminal justice system

reducingcertain costs incurred by law enorcement agencies

Ftre Research Topics and Implications for Polic and Practice

Te research presented in this guide is a useul oundation or making data-inormed decisions aboutpolicies and practices related to law enorcement encounters with people with mental illnesses. But itis just thata starting point. It does not negate the need or each community to conduct an analysiso its unique strengths and challenges. Once policymakers identiy programmatic goals that specicallyrespond to the ndings rom this analysis, they can design, implement, or modiy a program that bestts their communitys needs. A research-based response will support program sustainability and helpachieve systemwide eciencies when people with mental illnesses are prevented rom cycling through thecriminal justice system.


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Acknowledgments vii

This report could not have been writtenwithout the support and leadership othe John D. and Catherine . MacArthurFoundation and, in particular, Program

Associate Steven Casey. His guidance was instru-mental in raming the issue and ensuring thedocuments relevance to the eld.

Te National Institute o Mental Health

(NIMH), National Institutes o Health, U.S.Department o Health and Human Services,also provided support or the initial meetingo researchers and or the development o earlydocument drats. Ms. Denise M. Juliano-Bult oNIMHs Services Research and Clinical Epidemi-ology Branch was especially helpul during thiscritical phase o the project.

Tanks are also due to the members o theproject advisory board.* Tese leading research-ers, practitioners, and policymakers (listed

alphabetically below) provided early guidance onthe implications o the research and the rame-work o the document.

Mr.StephenBaron,Director,District oColumbia Department o Mental Health

Dr.GaryCordner,Professor,College o LawEnorcement, Eastern Kentucky University

Dr.JereyDraine,AssociateProfessor,Schoolo Social Policy and Practice, University oPennsylvania

Mr.RobertHendricks,ActingSeniorPolicyAdvisor or Mental Health, Bureau o JusticeAssistance, Ofce o Justice Programs, U.S.Department o Justice

Mr.AdamKirkman,ProjectAssociate,PolicyResearch Associates, Inc.

OcerJoanM.Logan,CrisisInterventioneam Coordinator,Montgomery County (Md.)Police Department

Ms.SusanE.Salasin,PublicHealthAdvisor,Center or Mental Health Services, SubstanceAbuse and Mental Health Services Administra-

tion, U.S. Department o Health and HumanServices

Dr.MelissaSchaeferMorabito,PostdoctoralResearch Fellow, Center or Mental HealthServices and Criminal Justice Research, RutgersUniversity and the University o Pennsylvania

Dr.HenryJ.Steadman,President,PolicyResearch Associates, Inc.

Dr.JenniferTeller,Professor,Department oSociology, Kent State University

Dr.AmyC.Watson,AssistantProfessor,JaneAddams College o Social Work, University oIllinois at Chicago

Special thanks must also be given to Coun-cilofStateGovernmentsJusticeCenterDirectorMichael Tompson, Health Systems and ServicesPolicy Director Fred Osher, and Consensus Proj-ect Director Nancy Fishman or their leadershipin shaping the scope and direction o this pub-

lication and ensuring its value to policymakers.Justice Center Director o CommunicationsMartha Plotkin was instrumental at each phase odevelopment; her input made this a more reader-riendly and useul contribution to the eld.

Acknowledgments

*Advisory board members titles and agency afliations reect the

positions they held at the time of their involvement with the project.


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Introduction 1

Headlines such as these appear every dayin newspapers across the country. Testories ocus on saety issues when lawenorcement ocers encounter an indi-

vidual whose behavior appears to be related toa mental illness. Tey also ocus on how ocers

come in contact with the same person with men-tal illness again and again, oten without positiveresults. Tey all express a common theme: thecomplex nature o law enorcement responses topeople with mental illnesses has become an issueo national concern, and policymakers, com-munity leaders, and the public are increasinglydemanding improved outcomes.

In the ace o mounting pressure and thedesire to better serve people with mental illnesses,law enorcement ocials are turning to special-

ized responses to people with mental illnesses. Inthese programsthe most common o which isknown as a Crisis Intervention eam (CI)lawenorcement agencies partner with mental healthand community groups to train police respond-ers to use crisis de-escalation strategies and toprioritize treatment over incarceration whenappropriate. Although specialized responses arerelatively new, hundreds o communities haveimplemented them since they rst appeared inthe 1980s.*

Specialized responses increasingly areregarded as having great potential to improvelaw enorcement encounters with people with

mental illnesses. However, they generally aredeveloped without the benet o research anddata documenting the scope o the problem theyare designed to address, the weaknesses o thetraditional response, and the relative importanceo specic program eatures. Rather, they have

spread as many such innovative practices do:practitioners and advocates provide anecdotalinormation attesting to the need and eec-tiveness o the programs and then work withpolicymakers to adapt other jurisdictions suc-cesses.isfrom-the-ground-upprocessmaybeappropriate or initial innovators, but, ultimately,programs developed based on data and researchare more eective and easier to sustain.

Modest research on law enorcementencounters with people with mental illnesses

and specialized responses does exist. As nationalattention to this issue has grown, so too has thepool o studies examining the various aspects othese approaches; however, there are still rela-tively ew comprehensive or in-depth studies.In addition, as more and more communitiesimplement the CI model and other types oresponses, an increasing number o local lawenorcement agencies and their research partnershave collected data to inorm their own programsdevelopment. Unortunately, the results otenpresent an incomplete or complex story thatdoes not necessarily translate into clear policyrecommendations.

Introdction

Mentall Ill Man with Gn is Shot and Killed b Police

1

Bed Shortage ForcesCont Mental Health Staff to Rel on Police2

Mom Knows Angish of Calling Police to Deal with Mentall Ill Son3

*Agencies engaged in law enforcementbased responses to people

with mental illnesses have implemented programs that require

signicant changes in law enforcement department policies and

procedures. This guide does not examine practices that rely solely on

mental health agencies to respond to incidents involving people with

mental illnesses.


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Law Enforcement Responses to People with Mental Illnesses2

In response to these perceived gaps, thisguide summarizes and helps translate the avail-able research on law enorcement encountersinvolving people with mental illnesses and strate-gies to improve these encounters. Based on anextensive review o the research by experts in theeld, this document presents illustrative examplesrom a range o studies representing diverse per-spectives on this subject. It is not meant to be anexhaustive inventory o the literature, but rathera guide to what the research tells us about lawenorcements response to people with mental ill-nesses, with support rom studies that refect thebody o knowledge in that area. Tis guide alsooutlines questions let unanswered by currentresearch. In so doing, the intention is to makesense o the inormation in a way that will inorm

policy and program design decisions and suggestuture topics or researchers to explore. Tis guideis divided into three sections.

SectionOne:EncountersBetweenLawEnorcement and People with Mental Illnessesexplores the extent, nature, and outcomes olaw enorcement interactions involving peoplewith mental illnesses. Te data demonstrate thescope o the problem and illustrate the chal-lenges and risks involved with these incidents.

SectionTwo:SpecializedLawEnforcementStrategies examines a range o law enorcementresponses specially designed to improve ocersencounters with people with mental illnesses

and their outcomes. Te data provide readerswith the context to understand the impact othese strategies on communities and the poten-tial eects on ocers attitudes.

Sectionree:FutureResearchTopicsand

Implications or Policy and Practice highlightsthe gaps in the current body o research thatcould help law enorcement better design itsprograms and policymakers determine howbest to allocate resources that would supportthese eorts. It also outlines the implications othe ndings presented in this guide or policyand practice.

Each section is organized around the ques-tions policymakers most oten pose, and, in

Sections One and wo, the guide providessuccinct answers that draw on existing research.

Te policy statements summarizing theresearch were developed with a group o expertsleading researchers, law enorcement andmental health practitioners, and policymakerswho participated in an advisory panel to provideinput on which studies to include, how to inter-pret the research, and the implications or policydevelopment.Withtheirhelp,thisdocumentismeant to bridge the gap between research and

practice, and to provide a springboard or policy-makers interested in supporting research-basedpractices.

Limitations and Details of the Research

THE AuTHORS DID NOT APPROACH THIS PROjECT WITH DEFINED CRITERIA for acceptableresearch methodologies, but chose to include data derived using a wide variety of methodologies,

some more rigorous than others. Because of the varied design sophistication, findings reflect a range

of validity and generalizability, and readers are urged to consider a specific studys methodology whenextrapolating from these data.

This document presents the most recent data available. Certain topics and questions have notbeen explored in depth in the past decade, so some studies from the 1980s and 1990s are included

to provide a thorough picture of the scope of research. The time period can be an important factor

when considering relevance, and readers should take this into account when examining the findings.

For more information about the challenges and apparent inconsistencies of law enforcement

research, see Appendix A.


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Section One: Encounters Between Law Enforcement and People with Mental Illnesses 3

Law enorcement ocers engaged in todays

community policing eorts inevitablyprovide citizens with services that go wellbeyond enorcing laws or maintaining

public saety and order. Law enorcement o-cers are rst-line, around-the-clock, emergencyresponders, mediators, reerral agents, counsel-ors, youth mentors, crime prevention actors,and much more. Among their growing list oresponsibilities is the need to eectively respondto people with mental illnesses. All too oten,individuals inadequately treated mental illnesses

are maniested in ways that can result in theircontact with law enorcementsometimes withtragic results. How law enorcement responds tothese individuals can have a tremendous impacton how encounters are resolved and what uturethese individuals can expect. Law enorcementsactions and perceptions oten determine whether

the individual will nd much-needed treatment,

continue in his or her current situation, or enterthe criminal justice system.

Experience in the eld has led rontlineocers to acknowledge they need more resourcesand training to respond to these challenging calls.Experts in the mental health eldincludingpractitioners, advocates, and individuals withmental illnesses and their amiliesagree andcan oer broad anecdotal support. Policymakers,however, need more than personal experi-ences; they need data that quantiy the natureand extent o the problem in order to commitresources and energy toward a potential response.Tis section highlights the research available toaddress this need by exploring the scope and scaleo law enorcement encounters with people withmental illnesses.

SECTION ONE

Law enforcement encounters with people with mental illnesses are relatively infrequent, but they can be

disproportionately time-consuming and complex. They often involve repeat contacts with individuals sus-

pected of low-level crimes or exhibiting nuisance behavior, without positive outcomes. Some encounters

do involve volatile situations that may place officers, the person with mental illness, and others at risk.

Enconters Between Law Enforcement

and People with Mental Illnesses


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Trends of People with Mental Illnesses in the Criminal jstice Sstem

FEW INSTITuTIONS HAvE ATTEMPTED SO COMPLETE a change in recent years as has the United

States mental health system. In 1964, driven in part by fiscal reality, political realignment, philosoph-

ical shifts, and medical advancements, Congress passed the Community Mental Health Centers Act.Since then, the system has shifted its emphasis almost entirely from institutional care and segrega-

tion to providing community-based support for individuals with mental illnesses. In 1955, there were

339 state psychiatric beds for every 100,000 people in the population. By 2005, this number had

dropped to 17 per 100,000.4 This process is referred to as deinstitutionalization.

Some observers suggest that deinstitutionalization is a main cause of the increased number

of people with mental illnesses in contact with the criminal justice system. In fact, no study has

definitively shown a transition of this population from mental health institutions to jails and prisons.

Other trends in criminal justice and mental health policyfor example, higher arrest rates for drugoffenses and underfunded community-based treatmentare likely to account for this populations

increasing contact with law enforcement, courts, and corrections.


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Research Findings

1. What tpes of enconters do law enforcement officers hae

inoling people with mental illnesses?

a. The majorityof law enforcement enconters with people with mentalillnesses are with indiidals sspected of committing low-level,misdemeanor crimes, or who are exhibiting nisance behaior.* Lawenforcement ma receie calls when a bsiness owner or commnitmember wants officers to do something abot a personwhether ornot a crime was committed.

Based on 148 contacts between police and people believed to have mental illnesses during one month

in 1994 in Honolulu (Hawaii) city and county, officers determined that the majority of individuals either

had committed no criminal offense (45.3 percent) or had exhibited disorderly conduct (27.7 percent).The persons conduct most frequently included loud or obnoxious behavior or untidiness.5

In a study conducted in a large Midwestern city in 1980 and 1981, the majority (71 percent) of police

encounters with people who were mentally disordered involved individuals known to officers either as

neighborhood characters, troublemakers, or relatively unobtrusive individuals.6

b. Law enforcement officers enconter people with mental illnesses at risk ofharming themseles.

In the first nine months of 2006, the Los Angeles (Calif.) Police Department made 46,129 contacts

with people suspected of having a mental disorder. Of those, 709 had attempted suicide and 4,686were taken into custody for an emergency evaluation.7

The Albuquerque (N.Mex.) Police Departments CIT program reported that in one year 15 percent of CIT

calls involved individuals attempting suicide, and 30 percent involved individuals threatening suicide.8

*Nuisance behavior refers to those actions that violate community norms by causing damage, annoyance, or inconvenience. Examples include

public drunkenness and loitering.

understanding Sicide-b-Cop

A 2006 LITERATuRE REvIEW determined that available data on incidents in which individuals intend

to end their own lives by engaging in criminal behavior to prompt a lethal response by law enforce-

ment officersknown colloquially as suicide-by-copare too flawed by methodology to provide areliable understanding of this phenomenon. However, when considered in its entirety, the body of

research does suggest that a mental illness and history of substance abuse, coupled with substanceuse at the time of the incident, are relevant factors in these events.9


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2. What is the extent of law enforcement officers enconters withpeople with mental illnesses?

a. A relatiel small percentage of total law enforcement contacts are inresponse to calls that inole indiidals who officers beliee hae mentalillnesses.

In a six-year period (19982004), the Akron (Ohio) Police Department responded to 10,004 calls

related to a mental disturbance. This represents 6.55 percent of the total call load (1,527,281 calls)

during that period.17

Approximately 12,000 emergency calls for service to the Los Angeles (Calif.) Police Department (2.3

percent) annually are coded as mental disturbance calls.18

*This sidebar was adapted from Reuland, M., Police Use of Force and People with Mental Illness. In J. Ederheimer (Ed.)Strategies for Resolving

Conict and Minimizing Use of Force. Washington, DC: Police Executive Research Forum, 2007.

c. Of all calls for serice inoling people belieed to hae mental illnesses,law enforcement officers enconter indiidals at risk of harming someoneelse relatiel infreqentl.

The Albuquerque (N.Mex.) Police Departments CIT program reported that in one year 14 percent of

calls for service involved a suspect possessing a weapon.10

Police officers in Honolulu (Hawaii) city and county noted that a persons behavior was assaultive or

violent in 12.2 percent of their 148 encounters with people believed to have mental illnesses.11

understanding Mental Illness and violence*

THE STEREOTyPE THAT PEOPLE WITH MENTAL ILLNESSES are more likely than the general popu-

lation to be violent is not fully supported by the evidence.12 Several large-scale research projects found

a weak statistical association between mental illness and violence.13 The association becomes stron-

ger, however, when a person with a mental illness has a co-occurring substance use disorder and/or isnot taking his or her medication.14 Still, it is important to note that research focusing solely on people

with mental illnesses who were involuntarily committed to a psychiatric facility may distort the rela-

tionship between violence and mental illness as these individuals represent only a small fractionthemost severely illof this group.15

Although data are scarce on the precise number of law enforcement field contacts with some-

one with a mental illness who is exhibiting violent or aggressive behavior, research shows that officers

do respond to calls for service that involve people with mental illnesses whose violent behavior is at

issue.16 For law enforcement policymakers, the critical question is not whether people with mental ill-

nesses are dangerous, but how best to maintain safety when violent or dangerous behavior results in

calls to law enforcement.


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b. Law enforcement officers repeatedly respond to a small subset ofindividuals whom the beliee hae mental illnesses.

Twenty percent of 507 calls for service identified as involving a person with a mental illness in one year

in Lexington (Ky.) occurred in just 17 locations; police responded to each of the 17 locations three or

more times in that year.21

In Santa Fe (N.Mex.), an analysis of a random sample of individuals taken into police custodyeither

through arrest, protective custody (for example, for intoxication) or involuntary mental health hold

indicates that people detained due to mental health or substance use problems generated significantly

more police contacts during the two-year study period than did those without ascertainable mental

health or substance use disorders. Individuals who had multiple prior detentions for mental health or

substance abuse problems or prior treatment for those problems were significantly more likely to be

taken into custodyeither through arrest or involuntary holdin the future.22

The Los Angeles (Calif.) Police Department identified 67 people with mental illnesses who had a

minimum of five contacts with law enforcement during the first eight months of 2004. This resulted in

a total of 536 calls for service during this time period.23

In 148 incidents involving people believed to have mental illnesses, police officers in Honolulu (Hawaii)

city and county recognized the person on sight in 94 of these encounters.24

c. Althogh the amont of time aries b disposition, officers can spendsignificant time tring to resole sitations inoling people with mentalillnesses, dring which the cannot respond to other calls for serice. Themost time-consming disposition is when law enforcement transports anindiidal to an emergenc medical facilit and waits for medical clearanceor admission.

The Lincoln (Neb.) Police Department handled more than 1,500 mental health investigation cases in

2002 and found that it spent more time on these cases than on injury traffic accidents, burglaries, or

felony assaults.25

Officers in Honolulu (Hawaii) spent a significant amount of time resolving incidents involving people

believed to have mental illnesses, varying by disposition. When transporting a person to a hospital for

an emergency evaluation, the officer spent an average of 145 minutes on the incident. When arrestinga person with a mental illness, the officer spent an average of 64.2 minutes on the incident. When

officers executed informal dispositions, incidents were resolved in 23.3 minutes on average.26

The Los Angeles (Calif.) Police Department reported spending more than 28,000 hours a month on

calls involving people with mental illnesses.27

In 1986, a suburban Colorado police department reported spending an average of 74 minutes

addressing each of the 60 mental health-related calls studied.28

Three percent of more than 12,000 police field encounters in two large cities involved someone who

was mentally impaired.19

In 174 U.S. police departments serving more than 100,000 people examined in 1998, approximately

seven percent of all police contactsincluding both investigations and complaintsinvolved a person

believed to have a mental illness.20


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3. What are the otcomes of law enforcement officers responsesto people with mental illnesses?

a. Thogh iolent otcomes are relatiel rare, law enforcement has reportedthat these enconters can present risks for all inoled.

According to FBI Uniform Crime Reporting statistics, during a ten-year period (19972006) 1,058

officers were assaulted and 13 officers feloniously killed in the line of duty when handling persons

with mental illnesses. This represents approximately 1.8 percent of all assaults and 2.3 percent of

felonious killings during this period.29

In the Police Executive Research Forum (PERF) 2004 study of 28 police departments with specialized

responses to people with mental illnesses, nearly half of the departments reported that a tragic

incident involving a person with a mental illness served as a main impetus for developing the program. 30

Officers surveyed in a study on police use of force considered mentally impaired people significantly

more threatening during arrests and required more effort to arrest, but did notconsider this

population more likely than individuals without mental impairments to inflict injury on officers.31

b. Officers handle a maorit of incidents informall b talking to the peoplewith mental illnesses, withot taking them into police cstod or connectingthem to treatment.*

Seventy-two percent of situations involving a person believed to have a mental illness in Honolulu

(Hawaii) were handled informally by counseling and releasing the individual at the scene (52 percent)

or with no action (20 percent).32

Findings from an observational study conducted in a large Midwestern city in 1980 and 1981

demonstrated that officers handled informally more than 70 percent of incidents involving people

with mental illnesses.33

*Informal actions in which the individual is not linked to services may be a contributing factor in repeat calls for service.

c. Officers sometimes take people with mental illnesses into cstod, eitherin the corse of an arrest or to proide transportation to a medical facilit.The freqenc of cstodial actions aries b risdiction.

Of calls for service involving someone with a mental illness during the two years before implementing a

CIT program, police officers in the Akron (Ohio) Police Department executed an arrest in three percent of

the calls and transported an individual to an emergency psychiatric facility in 26 percent of the calls.34

Law enforcement officers in Florida transported more than 40,000 people with mental illnesses for

involuntary 72-hour psychiatric examinations under the Baker Actthe states emergency evaluation

statutein 2000. This exceeded the number of arrests in the state during the same period for either

aggravated assault (39,120) or burglary (26,087).35

Officers in Honolulu (Hawaii) made an arrest in 14.9 percent of incidents involving individuals believed

to have mental illnesses. Officers were significantly more likely to arrest a person suspected of

committing a misdemeanor andknown to have a criminal history.36


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Section Two: Specialized Law Enforcement Strategies 9

Since the 1980s, law enorcement agen-

cies have increasingly collaborated withmental health providers and advocatesto design specialized responses to people

with mental illnesses. In a 1996 survey o special-ized law enorcementbased response programs(which studied U.S. law enorcement depart-ments serving populations greater than 100,000),the authors identied two primary responsemodels. Te rst type trains sworn ocers toprovide crisis intervention services and act asliaisons to the ormal mental health system; the

Crisis Intervention eam (CI) model, pioneeredin Memphis (enn.), ts into this category. Tesecond type partners mental health proession-als with law enorcement at the scene to provideconsultation on mental health-related issues andassist individuals in accessing treatments andsupports; this strategy is commonly reerred toas the co-responder model. Since both modelsrst emerged, the number o such specializedprograms has grown rom ewer than 30 reportedin the 1996 survey to more than 1,050 agencies

today.

SECTION TWO

Law enforcementbased specialized response programs have been shown to improve officer safety;

increase access to mental health treatments, supports, and services; decrease the frequency of these

individuals encounters with the criminal justice system; and reduce certain costs incurred by law enforce-

ment agencies.

Specialized Law Enforcement

Strategies

*The Criminal Justice/Mental Health Information Network (InfoNet),

coordinated by the Council of State Governments Justice Center,

includes examples of law enforcementbased specialized response

programs throughout the United States.

Calclating the Nmber ofLaw Enforcement Agencieswith Specialized ResponsePrograms

ESTIMATES OF THE NuMBER OF LAW

enforcement agencies with specialized

programs vary widely. The CIT Center at the

University of Memphis places the number

at around 1,050 communities, but oth-

ers have estimated far fewer.37 Differences

likely stem from two factors. First, thosebased on an online survey, such as the one

from the Criminal Justice/Mental Health

Information Network (www.cjmh-infonet.org) coordinated by the Council of State

Governments Justice Center, includes only

law enforcement agencies that submitted a

survey.* Second, program can be defineddifferently. Smaller estimates may refer to

agencies with fully implemented programs;

larger numbers may include agencies just

beginning program implementation.


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Although research has not yet documentedwhich program eatures are most critical to asuccessul program, agencies involved with spe-cialized response programs report that certainkey components o their programs contribute

to their success, including strong collaborativeties between law enorcement and mental healthservice providers and a broad range o training

or all relevant personnel.38 Another study sug-gestsjurisdictionsmusthaveaspecializedcrisisresponsesitetowhichocerscantransportpeople or ormal mental health assessment.Tis allows law enorcement ocers a quick

turnaround, minimizing the time they spendresolving these encounters.39

*The ndings in this document were corroborated through a

consensus-based project that resulted in theEssential Elements

(Schwarzfeld, Reuland, and Plotkin 2008) and involved multiple

reviews by expert policymakers and practitioners in several disciplines.

TheEssential Elements and related resources were supported by the

Bureau of Justice Assistance, U.S. Department of Justice, and are

available online at the Justice Center s Consensus Project website,

www.consensusproject.org/issue-areas/law-enforcement.

understanding Specialized Responses:A Brea of jstice Assistance, u.S. Department of jstice, Toolkit

THE COuNCIL OF STATE GOvERNMENTS juSTICE CENTER and Police Executive Research Forum(PERF) developed a series of resources that foster improved law enforcement responses to people with

mental illnesses. One of these practical materials is The Essential Elements of a Specialized Law Enforce-mentBased Program, which describes the 10 critical features in any successful law enforcementled

response.*

Other resources include a guide for overcoming common barriers to effective law enforcement

training on mental health responses, web-based information and peer-to-peer learning opportunities

(available on the InfoNet, www.cjmh-infonet.org), and case studies of statewide efforts to improve law

enforcement responses to people with mental illnesses. At this writing, an additional product in devel-

opment examines jurisdictions that designed law enforcement programs that have been tailored tounique challenges and community supports and services.


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Section Two: Specialized Law Enforcement Strategies 11

Research Findings

1. What is the impact of specialized law enforcement responses

to people with mental illnesses?

a. Departments emploing specialized responses to people with mentalillnesses experience decreasedinries to officers.

The San Jose (Calif.) Police Departments CIT program reported a 32 percent decrease in officer

injuries in the year following program implementation.40

The Memphis (Tenn.) Police Department reported that in the three years before implementing a CIT

program the rate of injuries to officers responding to mental disturbance calls was 0.035 per 1,000

events (equal to one in 28,571 events). In the three years following program implementation, this rate

decreased to 0.007 per 1,000 events (equal to one in 142,857 events). Other types of disturbance

calls, including domestic violence calls, did not show a similar trend during this period.41

b. Specialized responses increasethe freqenc with which law enforcementofficers transport indiidals to mental health facilities for ealations andtreatment, reslting in greater access to needed crisis and noncrisis spportsand serices.

In a study comparing the outcomes of calls handled by CIT-trained officers with those handled by non-

CIT trained officers in the Akron (Ohio) Police Department, CIT-trained officers transported people with

mental illnesses to psychiatric emergency services significantly more often than their non-CIT trained

counterparts.42

The Memphis (Tenn.) Police Departments CIT program reported that during its first four years, the

rate of referrals by law enforcement officers to the regional psychiatric emergency service increased by

42 percent.43

A three-city analysis comparing dispositions by responders in a CIT program, a co-responder program,

and a mobile crisis team revealed that officers in a police-based response were more likely than other

officers to transport individuals to mental health services or treatment and to resolve fewer incidents

informally.44

In a four-site study comparing outcomes for individuals diverted by police with those for individuals

not diverted, diverted individuals had greater access to mental health crisis services: 31.6 percent of

men and women diverted used emergency room (ER) services and 35.6 percent used hospital services.Of the nondiverted group, 25.7 percent used ER services and 20.6 percent used hospital services.

Diverted individuals likewise had greater access to noncrisis services: 81.6 percent received medication

and 57.5 percent received counseling. Of nondiverted individuals, 72.7 percent received medication

and 55.3 percent received counseling.45


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c. Indiidals referred to mental health treatment b law enforcement officersexperience fewer sbseqent contacts with the criminal stice sstem thanindiidals who were not referred to serices.

In an article summarizing studies of one-year outcomes of pre- and postarrest diversion programs,

diverted individuals with mental illnesses spent more time in the community without a related increasein arrests.46

2. What is the impact of training on law enforcement officersattitdes toward people with mental illnesses?

a. Specialized training improes officers nderstanding of mental illness andthe effects of mental illness on an indiidals behaior.

CIT training for law enforcement officers reduces stigmatizing attitudes toward people with

schizophrenia.53

d. Specialized law enforcementbased response programs hae mixed effectson the freqenc with which law enforcement officers arrest people belieedto hae mental illnesses.

A study that compared the outcomes of calls handled by CIT-trained officers with those handled by

non-CIT officers in the Akron (Ohio) Police Department showed no difference between the two groups in

numbers of arrests.47

In a study examining two specialized police-based programs (CIT and co-response) in policedepartments in Memphis (Tenn.) and Birmingham (Ala.), arrest rates of people with mental illnesses

were two percent and 13 percent, respectively.48 These rates can be compared with an earlier study

that noted a 16 percent arrest rate in a different community without a specialized police program.49

e. Specialized responses redce certain costs incrred b law enforcementagencies, inclding high-cost SWAT call-ots.

In studies of outcomes of pre- and postarrest diversion programs, diverted individuals with mental

illnesses incurred lower criminal justice costs and greater treatment costs than those who were not

diverted.50

The number of Tactical Apprehension Containment Team (TACT, similar to SWAT) calls in the Memphis

(Tenn.) Police Department has decreased by nearly 50 percent since the implementation of its CIT

program.51

Since the implementation of CIT in the Albuquerque (N.Mex.) Police Department, the use of SWAT

teams involving a mental health crisis intervention has decreased by 58 percent.52


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Section Three: Future Research Topics and Implications for Policy and Practice 13

There is still a lot to learn about law enorce-ment encounters with people with mentalillnesses and specialized responses. Teresearch ndings in Section One illustrate

the need or more inormation on law enorce-

ment responses to people with mental illnesses,and, although Section wo highlights somepromising specialized practices, many gaps in theknowledge base remain. Tis section highlightssome o those major knowledge gaps and dis-cusses how the state o the research aects policyand practice.

FuTuRE RESEARCH TOPICS

Te research presented in this guide providesa strong start to the study o law enorcementencounters with people with mental illnesses.However, when considered as a whole, the bodyo research also clearly reveals important gaps inthe knowledge base. o obtain a more completenational picture o these complicated encounters,

researchers must drill down into the specicso these interactions and their outcomes. (Forreaders interested in a more detailed potentialresearch agenda, see Appendix B.)

Althoughresearchtodateindicatesinjuryisanatypical outcome o these encounters, what isthe rate o injury to the ocer, the person withmental illness, and bystanders across a broadand diverse sample o jurisdictions?

Lawenforcementencountersinvolvingpeoplewith mental illnesses as oenders appear to berelatively inrequent, but how oten do ocersencounter people with mental illnesses as crimevictims?

Connectiontomentalhealthtreatmentservices can be an appropriate diversion orpeople suspected o committing low-level,nuisance oenses, but what can the mentalhealth system do to improve the eciency andeectiveness o this connection?

SECTION THREE

Ftre Research Topics and

Implications for Polic and Practice

A Call for Prospectie Research

MOST OF THE RESEARCH HAS BEEN RETROSPECTIvE, relying on information about past experi-

ences. In contrast, prospective research assesses a programs impact by examining data collected

before, during, and after implementation of a given program. Data from prospective research are

generally more reliable in assessing whether a program is effecting the positive outcomes it seeks, as

they provide more accurate, consistent, and objective findings. The body of literature on law enforce-mentbased specialized responses would benefit from methodologically rigorous, prospective research

designs that would examine the questions outlined here.


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Onceanagencyimplementsaspecializedresponse program, what inormation does itneed to collect to sustain it, and what are thebest methods to carry out the process?

Tese questions represent just a ew o themany holes in the research that, i lled, canbuild on the valuable oundation provided byresearch eorts to date and help guide policy-makers and practitioners in their eorts toimprove law enorcement interactions involvingpeople with mental illnesses.

IMPLICATIONS FOR POLICyAND PRACTICE

Te inormation in this guide can provide aconcise orientation to the issue and help policy-makers and practitioners interested in developingresearch-based arguments adopt or change pro-grams. As the ndings suggest, law enorcementencounters with people with mental illnessespresent a wide range o challenges, and, althoughthere is no single solution, specialized responseprograms and training can increase positiveoutcomes.

A pervasive limitation o the researchpresented in Sections One and wo is that theresults may not be generalized to other jurisdic-tions. Tis lack o universal applicability o thendings suggests that each community needs tostudy and examine its own unique circumstanceswhen developing or enhancing a specialized

response program. No two communities areidentical, and, although this research providesa broad understanding o some common issuesmany communities ace, it does not obviate theneed or an in-depth review o local problems

andresourcestoaddressthem.Whendecidingto design a specialized response program, policy-makers must take into account a variety o issuesthat can aect program design.*

Whatistheimpetusforchangeinthecommunity (or example, to reduce injuriesor repeat calls or service)?

Whatcharacteristicsofthejurisdictionmakeit unique (or example, demographics orgeographic distribution o resources)?

Whatmentalhealthresourcesareavailableinthe community?

Te research presented in this guide playsan important role in raming the discussion aboutimproving public saety, ocer saety, and out-comes or people with mental illnesses, but it isstill not well developed and should be just a start-ing point or community problem-solving eorts.Once policymakers identiy programmatic goals

that are specic to their communitys needs andresources, they can use the data collected by lawenorcement, mental health practitioners, andothers to supplement the research done to date.Tey can then consider the ull range o strategiesto achieve their goals and plan or modiy a pro-gram to achieve desired outcomes.

*The Justice Center and PERF are developing a resource that examines

jurisdictions that have developed a law enforcement program tailored

to their unique challenges and strengths. This product will be part of

the suite of materials developed with support by the Bureau of Justice

Assistance, and is described in more details in the sidebar Under-

standing Specialized Responses: A Bureau of Justice Assistance, U.S.

Department of Justice, Toolkit, on p. 10.


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Conclusion 15

The current body o research provides a win-dow into how specialized law enorcementresponses to people with mental illnessescan contribute to greater saety or all those

involved in encounters and provide better long-term results. Tough study design issuessuch assampling, methodology, and reporting errorsrequire cautious interpretation o the results, thendings can begin to inorm deensible policy andpractice.

Circumstances do not always allow time orpolicymakers to thoroughly investigate a problemin their community beore responding; tragic inci-dents can require quick decisions. Tis guide canhelp ready policymakers or a quick, responsibleresponse and assist them in communicating theresearch-based benets o instituting a specializedlaw enorcement response to people with mental

illnesses. It can also justiy the investment oresources in determining the scope o the problemin a particular jurisdiction. Once the decision toexplore a specialized response is reached, the addi-tional resources described in this guide can helpjurisdictions understand the essential elementsand particular considerations or any success-ul initiative. Although there is still much moreinormation needed to guide decision-making,researchers and practitioners who have contrib-uted to the current body o knowledge have putus on track to create collaborative law enorce-ment strategies that are based on the best thinkingandevidenceavailable.Withtheproperleadershipat all levels o government, that work can be con-tinued and carried out in jurisdictions across theUnited States.

Conclsion


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Appendix A: Understanding Apparent Inconsistencies in Law Enforcement Research 17

Researchers ace many challenges whentrying to explore and evaluate lawenorcement practices and policies. Spe-cically, when studying law enorcement

encounters with people with mental illnesses, aresearcher must rst dene mental illness. Te di-culty o this task is illustrated by the inconsistent

ways the studies cited in this guide dene anddescribe mental illnesses. Studies that use exist-ing law enorcement agency data typically usenonclinical terms and oten describe individualsbelievedtohaveamentalillness,basedonanocers impression. Studies that use data beyondexisting law enorcement reports tend to usemore rened denitions. Similarly, language usedto describe mental illnesses diers in communi-ties and across the country and has changed overtime. Troughout this guide, the authors preserve

both the original denitions and language used byresearchers.

Another obstacle that researchers ace isdeciding how to measure outcomes, or what thepolicy is trying to address, such as changes inarrest rates, calls or service, or total law enorce-ment contacts. Listed below are a ew possibleoutcome measures and the diculties associatedwith each option.

Arrest rates:Te arrest rates or people with

mental illnesses range rom three to 16 percent.Te dierent policies that govern ocer decision-making in certain arrest situations could explainthis broad range. Some jurisdictions mandatearrest in certain situations, whereas others provide

more discretion to responding ocers. Tis di-erence in policies can have a major impact onocers handling o calls in which mental illnessmay be a actor and, consequently, on arrest rates.

Calls for service: Data on the number ocalls or service coded as potentially involving aperson with a mental illness exclude eld contactsthat are not the result o an actual call or service(such as street encounters), calls inaccuratelycoded (logged as a trespass but not involving aperson with mental illness), or incidents thatresponding ocers could categorize as involving aperson with mental illness only at the completiono the call (a call or service is oten not recodedto indicate the encounter did in act involve a per-son believed to have a mental illness). As a result,using calls or service data likely underestimatesthe requency o law enorcement encounters withpeople with mental illnesses.

Total law enforcement contacts:Whencomparing dierent data illustrating the percent-ages o law enorcement encounters involvinga person with a mental illness compared withall law enorcement encounters, it is importanttounderstandhowdierentstudiesdenelawenforcementencounters.Forexample,theauthors rom one study reer to the total numbero calls or service, whereas another pair o authors

considers calls or service in addition to othertypes o contacts, such as ocers observing behav-iors while on patrol. Both methods are valid, butmay still yield dierent results.

Appendix A

understanding Apparent Inconsistenciesin Law Enforcement Research


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Some o the ndings presented in this guidemay appear contradictory or inconsistent becauseo the reasons described above and other varia-tions in terminology and methodology. Tis doesnot mean only one set o ndings is accurate,

but rather that readers should take into account

dierences o time, place, and methodology, andhow these actors can aect study outcomes. Forthose interested in reading more about a givenstudy, reer to the Bibliography or the originalresearch citation inormation.


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Appendix B: Detailed List of Research Questions 19

These research questions are not an exhaus-tive list o potential avenues or new study,but rather are illustrative o the directionnew eorts might take. Te authors identi-

ed these questions ollowing discussions withconsultants and reviewing the data that are cur-rently available. Tese questions remain largely

unanswered by the extant literature.

1. Information needed to better understandlaw enforcement encounters involvingpeople with mental illnesses:

a.Whatisthefrequencyoflawenforcementencounters with people with mental illnessesas the victims, not perpetrators, o crime?

b.Whatmeasurescanbecollectedtobetteridentiy the ull scope and nature o all law

enorcement interactions with people withmental illnesses?

c. How oten are people injuredthe ocer,the person with mental illness, a bystanderas a result o a law enorcement encounterinvolving someone with a mental illness, andin what circumstances?

2. Information needed to guide specializedresponse program development in a givenjurisdiction:

a.Whataspectsofcommunitycollaborationare most eective in developing these spe-cialized programs (e.g., number and typeo partners, meeting structures, participantactivities, accountability measures, groupprocesses)?

b.Whatelementsofthespecializedresponseprogram are critical to the programs successgiven a communitys unique characteristics?

c. How can rural jurisdictions adapt special-ized response models to be eective in theircommunity, particularly with limited accessto local mental health resources? And what

about very large urban jurisdictions specialconcerns?

3. Information needed to better understand thetraining involved with a specialized responseprogram:

a.Whattypeandamountoftrainingismosteective in changing ocer attitudes andbehavior on scene?

b. How does the quality o dispatch inorma-

tion aect the response?

c.Whatportionofthelawenforcementagencyshould receive what level o training to bemost eective?

d.Whattrainingprotocolismosteectiveinensuring an ocer trained in de-escalationis on scene quickly given local agency andcommunity actorstraining all patrolocers extensively, training only a subseto ocers extensively, or training all ocers

with de-escalation techniques while a subsetreceives more intensive training?

Appendix B

Detailed List of Research Qestions


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4. Information needed to better understandthe tactics, protocols, and proceduresinvolved in specialized responses:

a.Whatfactorsinuenceprotocoleectiveness?

b.Whattacticsaremosteectiveinsafelyde-escalating situations involving peoplewith mental illnesses?

c.Whatprotocols,tactics,ortechnologiesaremosteectiveinsafelyde-escalatingcriti-calincidents,thoseinvolvingpeoplewithmental illnesses who have weapons or areviolent?

5. Information needed to guide disposition

practices and policies:

a.Whatistherangeofappropriatedispositions?

b.Whatfactorsaectdispositionchoice?

c.Whatisthesafestwaytotransportpeoplewith mental illnesses in police custodythat minimizes the stress and stigma oconnement?

d.Whatprocedurespromotesafeandecient

custodial transer at the mental healthacility and ensure eective triage andreerral?

e.Whataretheclinicalchallengesforpeoplewith mental illnesses who are arrested? Howcan they be minimized?

f.Whatpolicereferralsandtreatmentproto-cols are associated with long-term wellness

and reduced repeat encounters with police?

6. Information needed to sustain a lawenforcement specialized response program:

a.Whatchangesareneededinthelawenorcement agencys policies, practices, andculture to support the specialized responseprogram and the personnel who urther itsgoals?

b.Whatarethenancialimplicationsofa

specialized law enorcement response?

7. Information needed to develop or enhancedata collection and evaluation practices:

a.Whatinformationshouldcalltakersobtainto acilitate on-scene response?

b.Whatinformationshouldbemaintainedinthe database to acilitate program evaluationand inorm uture calls?


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Notes 21

1. Vargas, Washington Post, May 16,

2007.

2. Hennessey-Fiske,Los Angeles Times,

November 21, 2008.

3. Erwin,Sacramento Bee, November 11,

2004.

4. NASMHPD Research Institute.2006

State Mental Health Agency Proles.

Alexandria, Va.: October 2007.

5. Green, Police as frontline mental

health workers: The decision to arrest or

refer to mental health agencies, 1997.

6. Teplin, Managing disorder: Police

handling of the mentally ill, 1984.

7. Wall, Los Angeles Police Department,

personal communication with the

author, March 2007.

8. Bower and Petit, The Albuquerque

police departments crisis intervention

team: A report card, 2001.9. McKenzie, Forcing the police to open

re: A cross-cultural/international

examination of police-involved,

victim-provoked shootings, 2006.



team: A report card, 2001.




12. For a scholarly review, see Harris andLurigio, Mental illness and violence:

A brief review of research and assess-

ment strategies, 2007.

13. Angermeyer, Cooper, and Link, Mental

disorder and violence: Results of

epidemiological studies in the era of

deinstitutionalization, 1998.

14. Steadman et al., Violence by people

discharged from acute psychiatric

inpatient facilities and by others in the

same neighborhoods, 1998; Swartz et

al., Violence and severe mental illness:

The effects of substance abuse and

nonadherence to medication, 1998.

15. Choe, Teplin, and Abram, Perpetrationof violence, violent victimization, and

severe mental illness: Balancing public

health concerns, 2008.

16. Panzarella and Alicea, Police tactics

in incidents with mentally disturbed

persons, 1997; Solomon, Cavanaugh,

and Gelles, Family violence among

adults with severe mental illness,

2005; Swartz et al., Violence and

severe mental illness: The effects of

substance abuse and nonadherence to

medication, 1998.17. Teller et al., Crisis Intervention Team

training for police ofcers responding to

mental disturbance calls, 2006.

18. Lodestar,Los Angeles Police Depart-

ment Consent Decree Mental Illness

Project: Final Report, 2002.

19. Terrill and Mastrofski, Situational and

ofcer-based determinants of police

coercion, 2002.

20. Deane et al., Emerging partner-

ships between mental health and lawenforcement, 1999.

21. Cordner, People with mental illness,

2006.

22. White, Goldkamp, and Campbell,

Co-occurring mental illness and

substance abuse in the criminal justice

system: Some implications for local

jurisdictions, 2006.

23. CSG Justice Center, Law Enforcement

Responses to People with Mental Ill-

nesses: Improving Outcomes, 2008.




25. Cordner, People with mental illness,

2006.




27. DeCuir and Lamb, Police response to

the dangerous mentally ill, 1996.

28. Pogrebin, Police responses for mental

health assistance, 1986.

29. U.S. Department of Justice, Federal

Bureau of Investigation,Law Enforce-ment Ofcers Killed and Assaulted,

2006, 2007.

30. Reuland and Cheney,Enhancing

Success in Police-Based Diversion

Programs for People with Mental

Illness, 2005.

31. Kaminski, Digiovanni, and Downs, The

use of force between the police and per-

sons with impaired judgment, 2004.






34. Teller et al., Crisis Intervention Team



Notes


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35. McGaha and Stiles, The Florida Mental

Health Act (The Baker Act) 2000

Annual Report, 2001.




37. Cochran, Department of Criminology

and Criminal Justice, University of

Memphis, personal communication

with the author, December 2008.

38. Reuland,A Guide to Implementing

Police-Based Diversion Programs for

People with Mental Illness, 2004.

39. Steadman et al., A specialized crisis

response site as a core element of

police-based diversion programs,

2001.

40. Reuland,A Guide to Implementing

Police-Based Diversion Programs for

People with Mental Illness, 2004.

41. Dupont and Cochran, Police response

to mental health emergencies

barriers to change, 2000.







44. Steadman et al., Comparing outcomes

of major models of police responses to

mental health emergencies, 2000.

45. Steadman and Naples, Assessing the

effectiveness of jail diversion programs

for persons with serious mental illness

and co-occurring substance use

disorders, 2005.

46. Ibid.




48. Steadman et al., Comparing outcomes

of major models of police responses to

mental health emergencies, 2000.



50. Ibid.






team: A report card, 2001.

53. Compton et al., Crisis intervention

team training: Changes in knowledge,attitudes, and stigma related to

schizophrenia, 2006.


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www.justicecenter.csg.org

Documents

LE Response to Mental Illness: Practice and Policy